The Ward Rounds Stitch-up

By Lorin McIntosh 

Still jet-lagged from my summer trip, I woke up at 7:30, instead of 6:30am. After a frantic morning routine, I make it to the hospital with ten minutes to spare. I have left my phone at home, had no breakfast or coffee, but I am determined to make it the best day.

 

As I walked through the white washed halls, a feeling of fear mixed with excitement sweeps through my veins. It is my first day of medical internship. I have been placed at Eastern Health, my top choice from my clinical years, and am beyond stoked to start my first day as a real doctor. After I arrive at my ward, I introduce myself to the team and begin to print off the lists. Just as I am finished stapling the lists (perfectly in the top left hand corner as my consultant has requested), another intern arrives. I do not remember seeing a fellow intern on the roster, but I am beyond excited when I realise that it is one of my medical school friends. We begin the ward round, just as the third-year medical students arrive.

 

Patient 1: Abdominal pain

As we begin to see the first patient, my consultant decides to ask me the anatomical landmark of the duodenojejunal junction. In a moment of fear and sheer panic, I do not remember my preclinical anatomical landmarks, and take a guess. The third year medical student then answers “the ligament of Treitz”. He then asks me to perform the DRE on the ward round, a sinister form of punishment for my incorrect answer.

 

Patient 2: Chest pain

As I am still trying to finish my note from the previous patient, we then see a patient presenting with central chest pain, radiating to the jaw and right shoulder, lasting for 20 minutes. The other intern orders troponins and I begin the process to take blood. As I am about to take the bloods, a clinical nurse educator walks into the doorway with a clipboard. I take the literal best bloods of my life and am beyond proud of my venepuncture win. The lady with the clipboard then announces that she is doing a hand wash audit for the hospital, and I have forgotten to wash my hands before putting on my blue nitrile gloves.

 

Patient 3: New onset neurological symptoms

My consultant is busy teaching the third year medical students about STEMIs versus NSTEMIs, and I decide to drag my computer to the next patient. As I am setting up outside the patient room. I notice that the patient looks a bit unwell. She has the classic facial droop and just appears a bit drowsy. I decide to go in and examine her, as my consultant is immersed in his tutorial. I note that she has a left sided facial droop, left sided arm weakness, and slurred speech. I run to my consultant and inform him that we need to call a “Code Stroke”. We call the code; the stroke team comes; there are literally like 20 people in this woman’s room. That is when the neurology registrar recognises the patient. I failed to check her medical history to see that she had suffered a stroke several weeks ago. Her current neurological issues reside around carpal tunnel syndrome in her right hand.

 

We see 12 more patients, and the rest goes fairly smoothly. In an attempt to redeem my atrocious ward round, I decide to attempt the Allied Health handover. My handover goes absolutely amazing, and I am beside myself. My consultant takes the team to coffee, and we celebrate our first day as a team.

 

After a glorious coffee, I spot one of my old registrars from when I was a fifth year medical student. We chat, and I tell him about all of the mistakes I made on the ward round. He laughs and we reminisce on his days as an intern, and he tells me that he knows an intern who had a worse day. He then tells me that his floor had an intern that did not even show up on her first day. I laugh and make a joke about how my floor had two interns. As he leaves, I internally panic and bee-line it back to the ward to check the roster. That is when I realise that I went to ward 7.2, not ward 7.1. It was me. I was the intern that did not show up on my first day.

 

Disclaimer: This is piece of creative writing and does not reflect the author’s beliefs about their own experience.  

The First Sip of Coffee

As I sit in this coffee shop beginning to write my article, the world continues to rush around me. Exhausted students with deep bags under their eyes thrust their keep cup over the counter as they order a triple shot. Businesspeople in elegant suits plaster a smile onto their faces as they sit down for their third meeting of the day. The waitress, who is already two hours into her shift, tries to ignore the pounding at her head as she glances back at the clock.

Week 9 has hit, and with it a tsunami of exhaustion.

In the past few weeks I have noticed that every time I ask someone how they are going I get roughly the same answers. Busy, tired and ready for a break. Everyone I talk to is grasping on by a thread for the break so that they can finally have a bit of rest. Maybe we will actually catch up on sleep. Maybe we will catch up with friends. Maybe, just maybe we will even catch up on the lectures. I don’t know about you, but I always feel like I am falling into the trap of looking forward. Dreaming so much of the mid sem break that I want week 9 to pass in the blink of an eye. Dreaming so much of the summer break that I want the rest of semester to just shoot past. And then, when it is over, I look back and wonder how it passed so quickly. Disappointed that my first year is over and I will never be able to get it back.

Why didn’t I appreciate it while it was there? When I hit the snooze button 3 times and crawled out of bed, did I appreciate that I woke up this morning? Did I appreciate that I was able to get out of bed on my own without the help of a nurse or walking frame? Did I appreciate that I had family or friends that I could contact at the click of a button? Probably not. I was likely so distracted by how tired I was that I forgot to acknowledge these things. Taking for granted what others would consider a luxury.

Is it the same for you? Do you ever find yourself wishing time away? Not really appreciating the days you have and the experiences that you are going through? I’m sure we all do it sometimes, especially as the semester comes to a close. So distracted by the hustle that we forget to just be present and enjoy it.

What can you do today that will help make you more present and appreciative of what is happening?

For me this can look like a few things:

  • Praying
  • Thinking about what I am grateful for
  • Turning my phone off
  • Keeping a journal
  • Making a cooked breakfast
  • Reading my bible
  • Going for a run or a walk without my phone
  • Mediation
  • Yoga
  • Study or read in a coffee shop
  • Taking the time to really appreciate my cup of coffee in silence

This list is definitely not extensive, but it is a start. A lot of the time they can even be paired. I have noticed that thinking about what I am grateful for can have the biggest impact and so while I have that cup of coffee, I thank God for specific things. How the lecture last week made more sense than usual. How my little sister calls me when she needs some advice. How my friend trusted me enough to confide in me.

Writing my journal is very similar, it just helps to get it on paper. To cement it a bit more, and to give me something to read back on when everything is falling apart. In fact, all of them are probably quite similar. They are just about stopping, being present, being grateful. It just takes 10 minutes but it makes a huge difference throughout the day.

The challenge I set myself is to make this a habit. To take 10 minutes every morning, every day to just enjoy that first sip of coffee.

Will you join me?

 

The Arena

By Michelle Xin 

Over 150,000 faces join me each day – yet another member of the infinite audience spectating the arena; my arena.

I watch and I wait, for I am always surprised by those who enter my realm, and I will never know who might be next.

There have been moments in time where I have speculated and predicted. Even moments where I have hedged my bets, because it was clear that this next individual inflicted with the plague will soon succumb, as did their predecessors. When they arrive here, they are lost and aghast. They fight and they rebel, for this was not the outcome that they deserved, nor the fate which their beliefs promised. They ask me for more years, for more cures to the maladies of their time, for another chance in another world. Their presence in the audience is begrudging and initially disruptive, but they take their seats eventually when time wears away at their mortal fire within.

However, in the recent years, I have hesitated to extend my foresight into the living as the care in which the mortals have now devised add sand to their depleting hourglasses. Their medicines and machines have stretched the boundaries of time and have challenged nature’s course and equilibrium. There have been many who I have expected sooner, and yet they continue to occupy their thrones of dialysis chairs with defiance and calm etched into their faces. There are endings which I have not yet witnessed because instead, I have witnessed the life jackets of tablets and transfusions and operations assisting individuals to remain afloat.

In centuries past, I longed for the stories of mortals; their earnest spontaneity inspired me, their unbridled suffering intrigued me, and each youthful emergence into my arena invigorated me – for their arrival in my arena allowed me to hear of their tales and their memories, both freshly made and freshly severed. When the floods of individuals crowded my realm during the eras of living brutality, I sought out the faces with age written on them and found too few. Their stories were bloodied, undeserved and chilling. I could not wish for those vivid recollections, despite how heartless the mortals may perceive me to be.

Even today, there are those with many projected years who have their hourglasses tragically and prematurely broken. Their faces should not be in the audience, although the mortal world is fickle and chaotic, and chaos brews unpredictability and sorrow in its darkest moments.

Now instead, I wish for time. For more sand to be poured into their hourglasses. For their living reality to last, because only time will prepare them for the finite.

There are fewer individuals who are lost and aghast when they arrive here. Instead, I am the one who is lost in the gratitude and peace I am confronted by. The mortals’ medicines and machines have taught them what I have seen but have yet to experience – that life is a fragile creature, but nonetheless worth nurturing and treasuring. That there is strength in belief, in humanity, in the comforting reassurance of words and arms. That encountering the end can be hopeful and uplifting, as all that has preceded it is a chance worth taking and living for.

The only request that I dare to issue is for these medicines and machines to persist and to evolve and to expand, in order to afford as many individuals with this chance to live before they discover my arena. Even though these medicines and machines are fighting me, I am sorry that I must win in the end. Know that the victories gained when the extra grains of sand find their way back into mortals’ hourglasses is worth the fight, the celebration and the memory, even if it fades into the mind’s recesses one day soon.

 

It is your victory to possess the treasured time of mortality. It is my loss that I, Death, must take that away.

 

 

Old organs

By Elizabeth Xu Yanning 

 

My first memory of a physician was that of my father, called in the middle of the day to certify a death. He operated a small general practice clinic at the bottom of an apartment block and I was working at his reception during my holidays. Although almost a decade ago by now, I clearly remember following his kyphotic back, confidently maneuvering through the labyrinth of housing developments with his battered black leather call bag.

 

We emerged from the clunky elevator to a sea of footwear surrounding the door of the apartment. A large party greeted us with warmth and snacks, almost like the Lunar New Year with a grim purpose. He lay waxen and emancipated, mouth agape in his bed, surrounded by three generations of offspring. I stood to the side dumbly, just outside the bubble of grief around the bed as my father did the necessary flicks, pulls and swings. Paperwork completed and family members briefed, we left.

 

Truth be told, this encounter only came to mind during my final year of medical school, in my Aged Care rotation in the sleepy foothills of the Melbourne suburbs. There I met 99-year-old Margaret*, resiliently drowning from the fluid in her lungs from her worn out heart. 86-year-old Jörg* who had had a fall, but grew a dangerous bacteria in his blood just before returning home. 75-year-old Lynn*, who was brought in vomiting faecal matter from a tumour mushrooming into her bowel lumen.

 

The solution to their problems could have been straightforward: diuretics, antibiotics, and naso-gastric tube or surgery respectively. However, none of these medical interventions were performed. Instead, in a direct violation to my medical schooled desire to treat, the team and their families opted for comfort care and let them slip slowly off into the night by death or to the Palliative Care unit.

 

There was no saving of lives, no normalization of vitals, no utilization of national standard management pathways. Was this still medicine as I’ve come to learn? The frantic MET call and tubing and masks and mess, often preserving life beyond the misfortune, yet equally often not.

 

At this point, I recalled my first encounter of patient care with my father. There was an absence of infusion lines and pills, but an abundance of counselling and comfort. This was the practice of medicine when medicine had failed.

 

All of us will encounter deaths of patients under our care and might wring our hands at our ineptitude. Before we lose hope, there exist three etymologies that offer insight to our profession.

 

Firstly, the Latin root word for doctor is “docere”, which means “to teach”. Long before the advent of miraculous anti-microbials, analgesia and anaesthetics, the physician’s primary role was to identify, understand and educate the patient on their malady. Their success as a doctor was not based on their ability to heal, but to communicate. Even as junior staff, we have basic medical knowledge that can make a tangible difference. We know the implications of treatment: its purpose, importance and pitfalls. Patients often don’t. Jörg’s bug turned out to be Staphylococcus Aureus, a nasty sticky thing that would have required 4-6 weeks of nauseating antibiotics through a long line in the arm. He refused treatment when we informed him of his options, with full capacity and family consent. For more collaborative and interpretive patient management, we require a shifting of perspective to understand what a patient does not see. It was and still is our core duty to provide good counsel, to aid patients in recognizing and accepting when they are dying. As the ancient Jewish text of Ecclesiastes says.

 

“There is a time for everything and a season for every activity under the heavens: a time to be born and a time to die.”

 

We might not have entered a medical career with this sole intention, but eventually all of us will have to guide a patient and their family in recognizing the approaching deadline.

 

Another derivative is for our patients, or “patiens”, which is Latin for “I am suffering”. Despite the age of remarkable scientific advancements that we live in, we need to recognise that there comes a point where fixing every problem in our patients becomes unfeasible and even inappropriate. Century-old Margaret in refractory pulmonary oedema had such a worn out heart that not even an artificial cardiac pump would have helped. Before her transfer out, the simple medicine she received included pain relief, dyspnea management and a steady supply of crosswords. Surely simple measures such as these are not any less important than cutting edge bioengineering, if the patient benefits. Medical science was made to help the patient, not for the patient to help medical science. The inability to heal is not our failure. This is echoed in Being Mortal, Dr Atul Gawande’s spectacular tribute to dying in the age of medical advancement.

 

“Medicine’s focus is narrow. Medical professionals concentrate on the repair of health, not sustenance of the soul. “

 

Palliative care changes this. It recognizes the value in treating the patient, not the disease.  The Latin root word “pallium” or “a cloak” reflects its nature, its practice a warm blanket to keep a patient comfortable, gently acknowledging their illness. This care is the responsibility of all doctors: to recognize the need for comfort early and to help patients die as well as possible. Lynn with a bowel obstruction passed on comfortably with the help of muscle relaxants and sedatives, bowels relaxed and quiescent, nausea abated.

 

However, medical science cannot provide all the information. To understand the price and the prize of medical treatment for the patient, we should understand the patient’s life; their values and their wishes. Medical treatments are only as valuable as how much they leave a patient able to have another precious moment to spend doing or being with what they love. Junior doctors often have the most time on the ward to explore this more deeply with patient and loved ones, passing onto the senior team members. We should never forget the simple power of simply knowing our patient.

 

As an intern, we will never make a palliative decision alone or purely on medical science. By understanding our patients’ pathology, pain and values, we may guide them to write their life’s epilogue. Let us not forget our own souls, for in our shared humanity, we provide genuinely compassionate care. As we grow in our humble role, we will mature into organizing Advanced Care Planning, leading family meetings and ultimately cessation of treatment. Like my simple old-schooled father liked to quote:

 

“Cure sometimes, treat often, comfort always.”

 

 

*Pseudonym to protect patient confidentiality

A ‘Band-aid’ Solution

As usual, it’s been a big day. As you’re sitting down to browse Netflix, a voice interrupts.

 

“Clean your room! Why haven’t you watched yesterday’s lectures yet? Check the mailbox”

“What’s the hurry?” you respond, “I’ll have the energy to do it later”

“Unpack your lunchbox!”

“But I could do it tomorrow morning as I get ready for class,” you counter.

“Have you put your clothes in the washing basket? The milk’s almost run out too.”

“Ssshhh – I’m trying to focus on Netflix! I don’t see any point doing my chores since they’ll all just pile up again anyway. Besides, I’m gonna die one day so why burden my years with mundane tasks – especially since the universe might be a simulation run by aliens and by the way what is the meaning of human existence?”

 

Okay. You’ve proven your point and convinced the opposing voice – your own better judgement – to let you leave your errands untended.

But somehow you don’t feel relaxed.

In fact, the room remains messy, the work not done, and you’ve been distracted by the dialogue in your mind. It becomes apparent you’re actually feeling uneasy not from your impending death and the world being a simulation but rather because of the strain of thinking about yet-to-be-done tasks – it’s as if you’re doing them, only you’re not; a band-aid approach.

 

The good news is, it doesn’t have to be this way. The solution: become a robot. A drone. A mechanised incognisant automaton. This way you can simply download software into your brain to get you to do your chores on autopilot – everything from making your bed in the morning to packing your bag for the next day or tidying your room.

 

If that’s too much for you, there’s always plan B – having a routine! This way you can still take the motivational mental debates out of the process in much the same (albeit a more human) way. By habitually ticking a few key things each day you can get a sense of achievement and clarity, and the tying-up of loose ends might help quell some of those late-night thoughts about all the things to do tomorrow. What’s more, moving through a routine can be fun (the only thing that tops singing in the shower is singing while washing dishes!) and an opportunity to practise mindfulness.

 

This isn’t to say be a perfectionist and follow a routine down to the word 365.25 days per year – a day off here and there can definitely be worthwhile in the long-run to help make it a smart goal. After all, generallybeing on top of a routine means that things are already in order and it’s okay to take a day off when needed.

 

The next day you’re arriving when home a familiar voice pops into your head:

“It might be a good day to go for a run,”

“Okay, let’s rip this off like a band-aid!”

 

15 minutes later you sit down, content with your efforts and fully relaxed.